Information Collection

State Agencies

IC 206841 under ICR 201911-0584-002 · OMB 0584-0584.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0584-0584 can be found here:

Documents and Forms

Document Name Document Type
Form FNS-843 State Agencies Form
FNS-843 Report of Disqualification from Participation - Institut Attachment A-1 FNS-843.pdf www.usda.gov Form
FNS-844 Report of Disqualification from Participation - Individu Attachment A-2 FNS-844.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	State Agencies	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 7 CFR 226.6(c)(7)(i)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FNS-843	Report of Disqualification from Participation - Institution and Responsible Principals/Individuals	Attachment A-1 FNS-843.pdf	www.usda.gov	Yes	Yes	Fillable Fileable
Form	FNS-844	Report of Disqualification from Participation - Individually Disqualified Responsible Principal/Individual or Day Care Home Provider	Attachment A-2 FNS-844.pdf		Yes	Yes	Fillable Fileable

Line of Business: Income Security

Subfunction: Food and Nutrition Assistance

Privacy Act System of Records
Title: USDA/FNS-11 Information on Persons Identified as Responsible for Serious Deficiencies, Proposed for Disqualification, or Disqualified to Participate as Principals or Family Day Care Home Operators in	FR Citation: 69 FR 6933

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,568	1,568
Annual IC Time Burden (Hours)	784	784
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.